Thursday, January 1, 2009

Emotional Trauma and the Development of the Idea of Neurosis in the United States: 1865-1930

Between the 1860s and the 1920s American psychiatrists expanded their nosology to include a new category - the neuroses. They also expanded their ideas of what counted as an acceptable medical explanation of psychiatric disorders to include what are now known as dynamic psychological explanations. The history of these developments has usually been told in terms of the introduction and acceptance of Freud's ideas.l The same story can also be told in terms of rivalry between two nineteenth century professional groups-asylum superintendents and neuroiogists-who later realigned to form the twentieth century profession of psychiatry.2 In addition, however,this

story can be told in terms of an emerging social and professional awareness of a puzzling syndrome of physical and mental symptoms which followed railway accidents in civil life and artillery shelling during World War I. Professional efforts to explain this syndrome and social conflict over its significance, resulted, it can be argued, in the construction of the idea that certain types of traumatic environmental events are causally linked with certain specific emotional symptoms. The concept of the traumatic emotional disorder gave legitimacy to the diagnosis of neurosis by demonstrating that "nerves" were more than a matter of a weak nervous system or poor heredity.

Prior to the late nineteenth century the psychiatric symptoms of soldiers might be diagnosed as due to nostalgia, that is, homesickness or to insanity but they were not attributed to the effects of battle.3 Psychiatrists did recognize moral causes of insanity such as fear and grief as well as physical causes such as fevers and blows to the head but they had not developed a causal model in which "trauma" mediated between circumstance and symptom. It can be argued that industrialization and the advent of industrial warfare created the social conditions which allowed this model to be constructed. It was not simply that people experienced emotional pain as the result of railway accidents or artillery shellings but that they held corporations and nations responsible for this suffering that gave rise to debate. Looked at from this point of view the history of the neuroses in the United States it is not simply an episode in the history of psychoanalysis nor in the history of the development of the psychiatric profession but a consequence of this debate over social responsibility for injuries.

RAILWAY SPINE

Controversy over responsibility for injuries began when passengers started filing damage claims against railway companies.Such claims were a significant source of litigation in England by 1860 and they grew in significance throughout the industrializing world as railroads expanded during the late nineteenth century. Indeed, litigation against railroads became one of the most prominent expressions of the discontents engendered by the process of industrialization. There were a number of reasons for this. Railway corporations were among the most visible of the impersonal corporations which were coming to dominate economic and social life. Railways accidents were frequent, terrifying and highly publicized instances of the capacity of industrial technology to maim and kill. Moreover, railway passengers did not confront the same obstacles to litigation as industrial workers.4

In 1866 the English surgeon John Eric Erichsen opened the medical debate over the emotional consequences of accidents with his On Railway and other Injuries of the Nervous System, which was Published in the United States the following year. 5 What concerned Erichsen was the spectacle of doctors disgracing the profession by disagreeing in court over claims made by accident victims. Erichsen noted that while "nineteen-twentieths of all railway or other accidents that are referred to surgeons" provoked no diagnostic controversies, there were many controversies over that small percentage of cases where "the relation between alleged cause and apparent effect may not always be easy to establish."6 To resolve these legal controversies Erichsen first argued that the problematic cases were sufficiently similar to constitute a syndrome, his description of which is worth citing at length:

at the time of the occurrence of the injury the sufferer is usually quite unconscious that any serious accident has happened to him.... When he reaches his home, the effects of the injury that he has sustained begin to manifest themselves. A revulsion of feelings takes place. He bursts into tears, becomes unusually talkative, and is excited. He cannot sleep, or, if he does, he wakes up suddenly with a vague sense of alarm. The next day he complains of feeling shaken and bruised all over, as if he had been beaten,.. After a time, which varies much in different cases, from a day or two to a more, he finds that he is unfit for exertion and week or unable to attend to business. He now lays up, and perhaps for the first time seeks surgical assistance. 7

After presenting 39 case examples, Erichsen went onto explain this syndrome pathoanatomically. He argued that the symptoms of what he called "concussion of the spine" were "in realty due to chronic inflammation of the spinal membranes and the cord." Cerebral symptoms, such as "headache, confusion of thought, loss of memory, disturbance of the organs of sense, [and] irritability of the eyes and ears," were indirect expressions of the spinal process.8 This was not,at the time, an implausible theory, and given popular sentiment about railway accidents, it was an easy one for many to accept. Indeed while Erichsen insisted that "concussion of the spine" occurred in a variety of accidents, the growing frequency and importance of railway litigation led virtually everyone to refer to Erichsen's discovery as "railway spine."

Throughout the 1870s railway spine reigned without competition as the diagnosis used by plaintiffs seeking damages for emotional symptoms following railway accidents. It was, by all accounts, a highly successful legal strategy. 9 The success of the diagnosis of railway spine, however, provoked harsh criticism. Erichsen's ideas were vulnerable to such criticism for several reasons. First, while Erichsen had aimed at improving the precision of medical testimony, the diagnosis of railway spine was sufficiently all-inclusive and vague that claims were easy to make. That Erichsen interpreted the clinical findings as due to an inflammation of the spinal cord, for which there was no treatment,implied a poor prognosis and consequently resulted in what many felt were exorbitant awards. Moreover the fact that victims of railway spine did not die meant that no patho-anatomical findings were available to support the diagnosis. Finally when accident victims were observed to recover after their claims weresettled, critics lost patience and cried malingering. As was frequently noted: The truth [was] that when juries find the medical evidence is conflicting, not being able to judge for themselves as to the merits of the case,they almost always decide in favor of the claimant.(an accident victim had) merely to go to bed, call in a couple of sympathizing doctors, peruse Mr. Erichsen's ...work on Railway Injuries [and], go to court on crutches...[to be assured a] jury would give large damages.10

The concept of concussion of the spine had few medical defenders. In the United States the National Association of Railway Surgeons published so many articles disputing the validity of railway spine in its official journal that one writer was led to suggest that "the destruction of belief in the so-called "railway spine" [was] the causa vivende" of the association.11 Not only railway surgeons criticized Erichsen. As R.M. Hodges noted in a paper presented to the Boston Society for Medical Improvement in 1880, Erichsen's work was "universally thought to present the subject in stronger colors than it deserves; to show an undue partiality for the public, and to be altogether too severe on the railroad companies."12

Nonetheless not everyone, not even all doctors, were distressed by the social consequences of accident litigation. In 1880 the prominent Boston neurologist James Jackson Putnam. for example, noted that "from a social standpoint" successful litigation stimulated railway authorities to be more careful to avoid accidents. He added that railway travel was safer in Europe and noted that, since the passage of stringent liability laws in Prussia in 1871, the cost in fines was no greater than paid in the United States by one railroad following a single accident.13 Consistent with these views on the value of successful litigation in promoting railway safety, Putnam also supported a view railway spine similar to Erichsen's. He argued that "such injuries... act...indirectly by causing minute haemorhages into the cord or its membranes" and he defended Erichsen's view that even such "definite lesions" might not manifest themselves immediately after the accident.14

Putnam's views on neuropsychological consequences of accidents are of particular interest for two reasons. First they reflect role that controversy over these accidents played in the construction of the psychiatric category of the traumatic emotional injury. They also provide a glimpse of Putnam's own dramatic evolution from a hostile opponent of the psychological to a leading exponent of psychoanalysis. Educated in Germany, Putnam was an influential proponent of a thorough going somaticism in the years after the Civil War. At a meeting of the American Neurological Association in 1876, for example, when George Miller Beard presented a series of experiments which tested "how much could be done in the way of effecting cures in cases of rheumatism, neuralgia sleeplessness, and various forms of chronic diseases by exciting in patients a definite expectation," Putnam replied that he "had never seen any evidence that cure had been effected by mental means in cases where actual disease existed."15 By 1909, however, Putnam was ready to enthusiastically welcome Freud, when the latter gave a series of lectures at Clark University, and by the time of his death in 1918, Putnam had become Freud's most influential Americandisciple.

While in 1880 Putnam's views on railway spine resembled Erichsen's, by 1883 they had changed dramatically. He no longer argued for the presence of minute hemorrhages in the cord but instead urged doctors, to search cases of apparent railway spine "carefully for the presence of functional symptoms which may be grouped under the term hysteria."16 This shift in opinion marked Putnam's first step on his way from somaticism to psychoanalysis. While he attributed this new opinion to his own observations, he also emphasized the influence of Jean Martin Charcot and Herbert W. Page in changing his interpretation of these observations. As Putnam noted, "there are few kinds of disease with regard to which the interpretation of evidence is of so much importance as compared with the simple accumulation of evidence as in the case of the so-called concussion of the spine."17

Page's "exceedingly valuable book," as Putnam referred to it, had been published only months before Putnam announced his new interpretation of cases of concussion of the spine. Presenting 234 cases of his own, Page argued that Erichsen had been misled by symptoms due to "injury to the extra-spinal muscular, and ligamentous structures" and had erroneously attributed "nervous symptoms" to a lesion of the spinal cord. Putnam was particularly impressed by Page's demonstration that the frequency of favorable outcomes in these cases was greater than his knowledge of serious disease would lead him to expect and that sprains and "reflex functional disorders" could simulate real organic diseases.18 Page explained this simulation by adopting a psychosomatic position. He argued that what he called "nervous shock" was a real disorder which could be produced by fear or alarm, but that it had a such better prognosis than concussion of the spine. Erichsen's syndrome, he explained, was produced by "neuromimesis," an involuntary process, which allowed a functional and curable disorder to mimic an incurable structural lesion.19

Although Page's motives for writing were certainly colored by the fact that he was a surgeon working for the London and North-Western Railway Company, his influence on Putnam was great because his views represented a compromise between Erichsen's views, which he so ably discredited, and the views or those who saw railway spine as nothing but compensation seeking. Putnam's eagerness to read Page as relatively sympathetic to accident victims is shown in his insist~ence that Page did not regard "rapid improvement after the settlement of legal claims ...(as) proof that the patient's symptoms were imaginary or assumed, an inference, (that) Putnam felt (was) often unjustly drawn."20 Interestingly Putnam ignored the fact that Page argued that with repetition functional disorders or mimicries could be brought on or terminated voluntarily. "Herein lies the explanation," Page wrote, "of those happily timed convulsions which occur when it is most important that you should see them..." as well as the "disappearance of mimicries" when the matter of compensation was settled.21

In spite of Page's somewhat idiosyncratic terminology, Putnam was able to respond as immediately and enthusiastically as he did because of the close parallel between Pages ideas and contemporary neurologic thinking about the functional interpretation of the symptoms of hysteria. The idea of the functional nervous disorder had a continuous history going back to Thomas Willis and William Cullen in the seventeenth and eighteenth centuries, but its significance as an explanatory concept had been eclipsed in the nineteenth century by enthusiasm for clinico-pathological explanations of nervous disorders.22 During the late nineteenth century, however, as Kenneth Levin has shown, efforts to explain all neurological symptoms pathoanatomically were blocked by the inability of neurologists to find lesions that would explain hysteria. 23 Some neurologists, like Putnam and Jean Martin Charcot, responded to this apparent failure by arguing that hysteria was a true, though functional, nervous disorder. Some functional cases, Putnam pointed out, "can be proved beyond the possibility of deception to be examples of that important neurosis hysteria a term which thanks to the labors of Charcot and his pupils, has vastly outgrown its old and vague meaning, and is constantly acquiring a mare precise and practical s;significance."24

This practical significance was particularly apparent in cases of railway spine. A functional diagnosis like hysteria because it was considered to have relatively good prognoses, offered the courts a way to acknowledge the legitimacy of many injury claims while limiting the damages awarded. Because hysteria was generally regarded as a disorder of women its symptoms were, however, thought of as being as unreliable as the women who complained of them. In court cases, as Putnam noted, "the admission of the diagnosis of hysteria is liable to throw a weapon for ridicule and disparagement into a skillful lawyer's hands."25 Hodges argued in 1880 that three fourths of the cases that he was familiar with were "really or probably deceptions.26 Putnam responded to concerns about malingering in several ways. He presented the case of a young woman whose injury did not occur in a railway accident and the case of a "large, powerful, and robust" railway fireman who developed hysterical symptoms following injury for which he was not filing a legal claim. He also reported several cases of accident victims who were unaware of their insensitivity to pain over one half of their bodies.27 This discovery of hysterical hemianasthesia was particularly important to Putnam because even if it was not a strictly objective finding, it was at least unlikely enough to be feigned, to have medico-legal value. It's discovery was also important enough as support for arguments for the legitimacy of the disease character of hysteria that Charcot cited Putnam's contribution;

While these controversies over hysteria were going on, a second psychosomatic disease--neurasthenia-- also came to be associated with the emotional effects of accidents. Unlike hysteria, it was rapidly accepted as a genuine disease. Originally described in 1863 by the American neurologist George Miller Beard, neurasthenia presented with a great variety of unrelated and vague physical symptoms, such as headaches, impotence, indigestion and exhaustion. It was understood physiologically as due to a lack of nerve force and was successfully treated somatically with electrotherapy, rest and overfeeding. Like hysteria neurasthenia was understood to have psychological causes. Following Beard it was most often explained as due to the stresses of advanced civilization.28 Neurasthenia was readily accepted because Beard's explanation of it as a physiological disorder due to the stresses of advanced civilization fit the expectations of many people who were anxious about the consequences of industrialization. Because neurasthenia was understood in this way, it was relatively easy for people to accept the idea that it might be caused by the terror of railway accidents.

By the end of the nineteenth century, neurologists had established a rough medical consensus that fright following accidents led to genuine, if not terribly serious, disturbances of the nervous system. Traumatic hysteria and traumatic neurasthenia successfully replaced railway spine as the accepted diagnoses for this condition. Erichsen's concept of concussion of the spine had only a few quixotic defenders such as S.V. Clevenger, who hoped to revive the concept by changing its name to 'Erichsen's Disease.'29 By the beginning of the twentieth century the courts too began to accept the utility of the concept of the traumatic nervous disorder, as a tool in resolving conflicts over responsibility In industrial accidents. With the advent of Workers' Compensation laws in England and the United States in the early twentieth century these diagnoses were applied not only to railway passengers but also to industrial workers.While there were special problems involved in establishing claims for emotionalinjuries under worker's compensation laws, the legitimacy of suchclaims was not a major source of controversy. 30

SHELL SHOCK AND WORLD WAR I

By the beginning of the twentieth century traumatic emotional disorders had acquired a limited role in accident litigation and workers compensation settlements and played a significant role in persuading some somatically oriented neurologists, like Putnam, of the importance of emotions In the formation of neuroses. Experience with traumatic emotional disorders during and after World War I contributed further to the acceptance of the neuroses. Martin Stonehas argued that in Britain "shell shock" rather than Freud's writings was critical to the expansion of the psychiatric enterprise to include the neuroses.31 In the United States the idea of unconscious mentalprocesses had achieved sufficient acceptance before 1917 that wartime experience played only a catalytic role in the more general acceptance of this idea.32 The perceived prevalence of these disorders during the war and the apparent success of the American Expeditionary Force in treating them helped persuade many Americans that neuroses were common treatable disorders. At the same time as Americans were using experience with shell shock to promote optimism about the neuroses, however, they were beginning to see large numbers of ex-servicemen who were not recovering from their wartime experiences. The sight of these veterans whose neurotic symptoms did not dissolve as expected after the war reopened the question of who was responsibility for this form of suffering.

Preparation for the treatment of shell shocked soldiers by the American Expeditionary Force began in May 1917 when Thomas Salmon, with the approval of the war department and the support of the Rockefeller Foundation, went to England to study British treatment methods first hand.33 In December of that year he was appointed Director of psychiatry for the AEF. Salmon was well suited for the task of creating an organization to care for the expected wave of wartime psychiatric casualties. While serving in the public health service between 1903 and 1912 he had been responsible for screening immigrants for insanity and had become quite concerned about the threat these immigrants posed to the mental health of the nation. In 1912 he left that position to become director of the National Committee for Mental Hygiene. The National Committee had been founded in 1910, two years alter Clifford Beers, a former mental patient, had published his influential book A Mind That Found Itself. Beers hoped to use this book to establish a national movement to improve the conditions of the hospitalized mentally ill. Influenced by the prominent psychiatrist Adolf Meyer, however, the National Committee shifted its focus to an educational program aimed at preventing mental illness. As director of the National Committee Salmon devoted his statistical talents to surveying the mental institutions and calling attention to what he saw as the growing problem of mental illness.34 Even before traveling to England Salmon had gathered considerable information about the occurrence of mental illness in the military. He noted, for example, that the prevalence of mental disorders among the troops on the Mexican border In 1916 was three times that in New York State. 35

By the time Salmon came to England controversies over "shell shock" had largely been resolved. The term was originally used to describe soldiers who developed neurological symptoms during battle in the absence of signs of physical injury. The term derived from the initial belief that these symptoms were due to changes in the nervous system produced by the sudden changes in atmospheric pressure produced by exploding shells. Initially, the victims of "shell shock," like those of railway spine, were caught up in controversy over whether they suffered from a form of brain damage or were merely malingering. The serious and ultimately unacceptable social implications of labeling thousands of soldiers either cowards or insane gave advocates of functional and psychological notions of traumatic emotional disorders an opportunity to promote the socially more usefulcompromise suggest;on that shell shock was a real disorder, but one which could be readily treated by psychological means.36 By the time the United States entered World War I both the British and the French had agreed that the most effective way to return soldiers to battle was to treat them close to the front and return them to the trenches quickly. Two broad psychological interpretations of these symptoms had developed. The first stressed the role of suggestion and was treated by counter suggestion. Soldiers who could not speak, for example. were painfully stimulated until they screamed, thereby demonstrating that they could speak. The second stressed the role of psychological trauma and conflict and was treated with the abreaction of painful memories.

Salmon and other leaders of the American effort to deal with Psychiatric casualties of the war quickly adopted British psychological views on the war neuroses and their treatment. This was in part due, of course, to the fact that Salmon studied British efforts first hand but also to the fact that ideas about unconscious or subconscious mental processes had achieved a substantial foot-hold in the United States before the war. By the turn of the century avirtual psychotherapeutic school had developed in Boston around Putnam, the neurologist Morton Prince and the psychologist William James. Widespread interest developed after 1906. In that year Pierre Janet, who was viewed as a representative of the "school established by Charcot," delivered an important series of lectures on "The Major Symptoms of Hysteria" at Harvard University and Morton Prince published his The Dissociation of a Personality, which brought the subject of multiple personality before a wide audience. By July 1907 seventy-nine papers and ten books were listed in the Index Medicus under the heading "psychotherapy" --a heading which had first appeared only in May 1906. In 1909, Freud, who thought his ideas would be anathema in the United States, was surprised by the warm reception he received when he spoke at Clark University.37

Salmon returned from England with the view that "whatever the unknown physiological basis, psychological factors are too obvious and too important in these cases to be ignored."38 While he accepted the commonly held view that the uniquely terrible conditions of the fighting made World War I the first war in which the traumatic neuroses were observed, his emphasis was on the vulnerability of individuals not the conditions of fighting. He rejected the term "shell shock" because by 1917 the evidence clearly showed that only a small number of cases occurred in the presence of shell fire. He held that the largest group of cases consisted of individuals who were exposed to conditions no different from those which hundreds of their asymptomatic comrades experienced. These cases, he added, resembled 39 Salmon also supported those seen in civil practice in most respects his psychological view by pointing to the high ratio of officers to men among the "shell shocked," the rarity of war neuroses among prisoners and the wounded, and the success of psychological treatments. Because Salmon adopted a psychological point of view he could also accept the controversial distinction between malingering and hysteria, insisting that the hysteric unconsciously deceived himself about his disability.40

Along with the psychological orientation of his British mentors, Salmon also accepted the British view that the most effective treatment must occur close to the front where every effort could be made to return the soldier to the fighting. Salmon insisted that such treatment not only promised to increase the manpower available for the war effort but also to reduce morbidity from the war neuroses. While he accepted that fact that relatively few men could be returned to the front and consequently the results of treatment might be disappointing to the military, he rejected the idea of simply discharging all cases of she:l shock. That, he argued, would encourage the use of neurosis "as a way out."41

Salmon!s ideas about treatment were based on his opinion that "the Psychological basis of the war neuroses (like that of the neuroses in civil life)...(was) an elaboration, with endless variations, of one central theme, escape from an intolerable situation in real life to one made tolerable by the neurosis."42 Sidney Schwab, L. a theoretically inclined American neurologist, grounded similar views on the vulnerability of shell shocked soldiers on Freud's idea of defense and British ideas on the instinct of self-preservation. He argued that even normal individuals erect neurotic defenses to protect themselves from psychological as well as physical trauma.43 What was critical was the individual's vulnerability. For Schwab the war demonstrated that "any soldier under given circumstances would develop a neurosis... (but that) the potential neurotic not only developed a war neurosis under less intense traumatic environment than the normal soldier, but ...was less capable of cure."

AFTER THE WAR

American involvement in the war was brief and the operation or the "forward treatment" strategy even briefer. Nonetheless Americans were proud of both their success in screening out potential psychiatric casualties and in treating those which occurred. After the war Americans asked what lessons could be learned from wartime experience with the neuroses. Views such as Salmon's about the nature of the war neuroses were widely held. Such views of the dynamics of the war neuroses led to optimistic predictions of post war recovery and did not prepare Americans for the problems of chronic shell shock. Because Salmon regarded neuroses as an "escape" from intolerable c;circumstances, he concluded that "with the end of the war most cases, even the most severe, will speedily recover, those who fall to being constitutionally neurotic.''44 E.E. Southard also insisted that ''in a period of not over two years after the war experience is over these men should get back to their normal emotivity..."45 Fredrlck W. Parsons commanding Officer of Base Hospital No. 117, which served as the primary treatment facility for the war neuroses noted that"practically all" cases treated at his hospital recovered. Parsons, however, anticipated post war problems with chronic shell shock even as he reassured his readers that:

a war neurosis which persists is not a creditable disease to have, as it indicates in practically every case a lack of the soldierly qualities which have distinguished the Allied Armies, and it will not be a serious problem. The population of the United States will easily absorb the few scores of unrecovered cases that will exist after the expiration of six months of peace, and no one should be permitted to glorify himself as a case of "shell shock."46

The apparent success of the AEF in preventing and treating war neuroses allowed doctors to draw a number of morals for the treatment and prevention of civilian neuroses from their experiences with the wartime variety. The lesson for post war America, Schwab concluded, was that "an individual who has failed to adjust himself to the demands of civil conflict implied in the struggle for existence and to the economic social stresses, through the compromise of a neurosis, must be regarded as a citizen soldier for whose concern the community is responsible."47 Norman Fenton, who regarded war neuroses which persisted or recurred as like bad habits, warned parents and teachers that "through neglect or unwise attitudes ... (they might) be partially responsible for the genesis of such symptoms in children."48

Austen Fox Riggs, who established a successful residential center for the treatment of the neuroses in Stockbridge Mass. before the war,for example, also drew a moral for post war civil life from his optimistic understanding of the psychodynamics of the war neuroses. For Riggs shell shock was due to a soldier's failure to recognize that fear was not "synonymous with cowardice," but a normal reaction to danger and an "occasion for courage." Given enlightenment on matters such as this, Riggs was quite sure that in "complicated neuroses of ordinary civil life" as well as war neuroses, the patient could find "the will to get well, ready to apply itself" to the problem of adjustment.49

The war neuroses were, however, not as easily treated as Riggs' optimistic rhetoric would have suggested. Paul Fredrick Slocum, a graduate of Yale and a first lieutenant, for example, was dazed and suffered from severe pain in his neck following exposure to an explosion during the war. Riggs diagnosed him as suffering from a war neurosis when he treated him for six weeks in 1920. In spite of this Slocum spent at least the next decade unsuccessfully seeking treatment alone and compensation for his symptoms. 50 Lieutenant Slocum was not alone his protracted struggle with the effects of the war. Norman Fenton's followup of ex-servicemen treated at Base Hospital 117 showed that in 1919-1920 forty percent were still disabled by symptoms and that in 1924-5 twenty percent remained so. Salmon expressed concern that "misdirected sympathy or ...misdirected harshness,...frequent transfers from hospital to hospital with consequent varied diagnostic notions...(contributed to) the fixation of symptoms."51 Fenton, however, also suggested that social factors played a role in recovery, noting that individuals with clerical and professional backgrounds made much better adjustments than those who worked in agriculture, mining and transportation. He interpreted this in terms of the greater intelligence of the former. 52 Douglas Thom's observations on how ex-servicemen sought out treatment, however,suggested that social and economic factors, particularly in the difficult years immediately after the war, may have played a greater role than intelligence. He noted that the majority of such patients "returned to their homes after the war and for a longer or shorter period adjusted themselves to the old environment." Subsequently, "accident or illness to the patient, possibly some sickness in the family or financial loss, more likely unemployment or domestic difficulties...act(ed) as the exciting cause of a so-called nervous breakdown. It is during this period of social and economic maladjustment that the individual makes first contact with one of the ~numerous agencies interested in the ex-serviceman."53

Some reacted to the unexpected prevalence of neurotic ex-servicemen by insisting that provisions made to provide for their care were contributing to their neurotic disability while others insisted that these provisions were inadequate. To provide for the care for ex-servicemen after the war, Congress, in 1917, amended the War Risk Insurance Act, a law which had been passed to provide insurance for commercial shipping in wartime. Congress took this approach rather than utilize the pension system which was developed after the Civil War because, in the words of a contemporary observer,that "patchwork of pensions (was) based on gratuities and political favor rather than on a sense of social justice and mutual obligation, (and was) universally recognized as a failure."54 In order to avoid such corruption the amendment to the War Risk Insurance Act provided for optional life insurance and universal compensation in the case of disability. The compensation provision resembled the workmen's compensation laws which had been passed in many states during the previous decade. Soldiers would be compensated only for injuries incurred during the war and the War Risk Insurance Bureau was empowered to establish this service connection and the degree of disability. To make the operation of this Bureau fair and practicable all service men were assumed to have been able bodied at the time of their admission to the service.The provisions of this amendment created special problems in cases of neurosis.

The presumption that American soldiers were mentally healthy at induction was justified by the fact that the psychiatric service of the American Expeditionary Forces had established an elaborate and extensive program of screening recruits for mental disorders including the neuroses. They hoped that this screening would reduce the number of wartime psychiatric casualties; and after the war, they took pride in the overall success of their efforts. Nonetheless, even before the war was over, some neuropsychiatrists were expressing bitterness about the terms under which they had to treat neurotic soldiers. Pearce Bailey, a neurologist with considerable prewar experience with railway spine, for example, noted that:

In our army the task of the cure of patients is difficult by reason of the sweeping application of the principle of compensation for disability. ...Legally, no disorder can have preexisted in a person accepted for military service. As far as the neuroses are concerned, this law puts it beyond the power of medical officers to throw any doubts into the mind of the patient that he will surely be compensated if he persists in his long enough. 55

That compensation was payable only for disability directly connected with service meant that benefits were payable to a relatively small number of men. Immediately following the war there was little difficulty in establishing service-connection, but with each passing year this connection became more and more difficult to establish, Particularly for tuberculosis and neuropsychiatric diseases.This resulted in considerable litigation to establish service connection as well as disability.

In 1921 Senator Walsh of Massachusetts proposed legislation to eliminate the delay and annoyance created by "requiring the disabled soldier to prove that the disease from which he is suffering was contracted in the line of service." What particularly concerned Walsh was the disabled veteran who had sent proof that he was suffering from tuberculosis or a neuropsychiatric disease to Washington only to be told that: "The burden is upon you to prove that the disease was contracted while in the service of your country." He felt that requiring proof of service connection had been responsible for much of the "complaints, dissatisfaction, and disappointment" with the War Risk Insurance Act. Walsh felt that his legislation was justified by the fact that so many ex-service men suffered from tuberculosis and nervous and mental diseases. After all he asked rhetorically, "Where did they acquire these diseases?" "Surely," he concluded." the young manhood that you and I knew and grew up with were not so generally and promiscuously afflicted with tuberculosis or nervous or mental diseases.''56 When it finally passed Walsh's legislation contained thefirst departure from a strict requirement of service-connection, It provided that a veteran with active tuberculosis or a neuropsychiatric disease causing a disability of 10 per cent or more, developing within two years after separation from service, would be considered to have acquired his disability in service." 57 In 1924 the World War Veterans Act extended the date of this presumptive service connection to January 1, 1925.58

It is not necessary to review the obvious influence of veterans politics on the passage of Walsh's legislation. It is sufficient to note that the passage of Walsh's legislation indicated that the problem of shell shock was not going to evaporate after the war as Salmon's psychological formulations had led people to believe. More generally the passage of Walsh's legislatlcn demonstrates how difficult it is to separate the relationship between trauma and emotional disorders from social and politlcai processes. Traumatic emotional disorders continue to be a source of social conflict as recent debate over post traumatic stress disorder among Vietnam veterans and the victims of childhood sexual abuse makes clear. With the perspective provided by the history of railway spine and shell shock it should also be clear that such conflict is to be expected because claims of emotional injury inevitably raise questions of responsibility. This perspective should also help us to see that the process by which our understanding of traumatic emotional disorders is shaped cannot be completely understood without taking social conflict into consideration.

1.John C. Burnham, Psychoanalysis and American Medicine,l894-1918:Medicine, Science and Culture (New York:International Universities Press,1967); Nathan Hale, Freud and the Americans:The Beginnings of Psychoanalysis in the United States.1876-1917, (New York: Oxford University Press,1971)

37 .John C. Burnham, Psychoanalysis and American Medicine.; Nathan Hale, Freud and the Americans; Edward M. Brown, "The Influence of Neurology on American Psychiatry,l865-1915." http://members.home.net/edwardmbrown1/historyofpsychiatry.html